Oligometastatic sarcoma treated with Curative intent Ablative Radiotherapy (OSCAR): A multicenter study on behalf of AIRO (Italian association of Radiotherapy and clinical Oncology)

BACKGROUND AND PURPOSE

Stereotactic Ablative Radiotherapy (SABR) is emerging as a valid alternative to surgery in the oligometastatic setting in soft tissue sarcomas (STS), although robust data are lacking. The aim of this study is to evaluate toxicity and efficacy of SABR in oligometastatic STS.

MATERIALS AND METHODS

This is a retrospective multicenter study including adult patients affected by stage IV STS, treated with SABR for a maximum of 5 cranial or extracranial metastases in up to 3 different organs. SABR was delivered with ablative purposes. Study endpoints were overall survival (OS), local control (LC), distant progression free survival (DPFS), time to polymetastatic progression (TTPP), time to new systemic therapy (TTNS) and toxicity.

RESULTS

From 10 Italian RT centers, 138 patients (202 metastases) treated between 2010 and 2022 were enrolled in the study. Treatment was generally well tolerated, no acute or late toxicity ≥ G3 was recorded. Median follow up was 42.5 months. Median OS was 39.7 months. Actuarial OS at 1 and 2 years was 91.5 % and 72.7 %. Actuarial LC at 1 and 2 years was 94.8 % and 88.0 %. Median DPFS was 9.7 months. Actuarial DPFS at 1 and 2 years was 40.8 % and 19.4 %.

CONCLUSION

SABR is a safe and effective approach for the treatment of oligometastatic sarcoma. One out of 5 patients is free of progression at 2-years.

Preoperative Radiotherapy of Soft Tissue Sarcoma with Simultaneous Integrated Boost: A Phase II Study

PURPOSE/OBJECTIVE(S)

Neoadjuvant radiotherapy to 50 Gy in 25 fractions is delivered in operable Soft Tissue Sarcoma (STS) patients to downstage the tumor and improve resectability, although at the expense of increased risk of wound dehiscence. Nonetheless, clear margin resection (R0) may not be achieved in tumors located in proximity of critical structures such as the neurovascular bundle (NVB), resulting in impaired local control. The aim of this study is to increase R0 rate through addition of an IMRT boost to the potential sites of suboptimal resection in STS patients receiving neoadjuvant RT. We report hereby the dosimetric results and safety results from the first 5 patients enrolled in this trial.

MATERIALS/METHODS

We designed a prospective monocentric interventional single-arm Phase II study enrolling locally advanced STS eligible for surgery. RT is administered in 25 daily fractions to include the MRI-based Gross Tumor Volume (GTV) and peritumoral tissue at risk of microscopic spread (CTV1) to a dose of 50 Gy (2Gy/fraction), with SIB (Simultaneous Integrated Boost) intensification to the tumor/dissection plane interface (CTV2) to a dose of 60 Gy (2.4 Gy/fraction). CTV2 delineation is approved by both a Radiation Oncologist and Surgeon. A margin of 0.5 cm is applied to both CTV to obtain PTV1 and PTV2. Concurrent anthracyclines-based chemotherapy (ChT) is allowed up to 3 cycles. Primary endpoint is R0 resection rate. Secondary endpoints include pathologic complete response rate, objective response rate, overall survival, local and distant progression-free survival, acute and chronic toxicity rate. To assess an increase in R0 rate from 81% to 97% assuming β = 80% e α = 0.05, 33 patients will be included. Dose constraints are summarized in Table1. At least 95% of the PTV1 and PTV2 should be covered by 95% the prescription dose up to a maximum allowed dose of 107%.

RESULTS

Five patients were included. Tumor was located in the limbs and in the trunk in respectively 4 and 1 patient. Mean age was 47 years (range: 19-67). Concurrent chemotherapy was performed in 2 patients. Mean GTV size was 228.6 cm3 (range: 59.8-314.5). Mean PTV coverage by the 95% of the dose prescription was 98% (95-100) and 97% (95-100) in PTV1 and PTV2, respectively. Mean PTV1 and PTV2 Dmax were 61.6 Gy (range: 59-63) and 64.1 Gy (range:63-66), in both cases below the 107% threshold. Mean Bone Dmax was 55 Gy (56.6-61.8 Gy). Dmax to the skin corridor exceeded 20 Gy in 1 patient (range 12.5-58.1). While the NVB was overlapping the PTV2 in all cases, Dmax was below 66 Gy. At the time of this report, no Grade ≥3 acute skin toxicity was observed. Two patients underwent surgery with a radiological partial response (RECIST) and pathological complete response. No major wound complication was reported.

CONCLUSION

Planning goals of the first 5 enrolled patients are achieved in most cases. Preliminary results show a benign safety profile and promising tumor response rate.

Clinical Outcomes and Dosimetric Predictive Factors in Patients Undergoing Reirradiation for Recurrent Meningiomas

PURPOSE/OBJECTIVE(S)

Re-irradiation (reRT) of intracranial meningiomas is often limited by radiation tolerance of the surrounding normal tissue and the risk of side effects. Aim of this retrospective study is to report outcomes, toxicity and prognostic factors of reRT in a large cohort of patients with recurrent meningiomas (RM) treated with different RT techniques.

MATERIALS/METHODS

A multi-institutional database of intracranial meningioma patients who recurred after prior radiation treatment was collected. Patients underwent reRT with one of the following techniques: radiosurgery (SRS), multi-fraction stereotactic radiotherapy (f-SRT), proton therapy (PT), Intensity-Modulated radiotherapy (IMRT) and External Beam radiotherapy (EBRT). Biologically Equivalent Doses in 2 Gy-fractions (EQD2) and Biological Effective Dose (BED) for surrounding normal tissue and tumor were estimated for each RT course, assuming an a/b = 2 for brain tissue and a/b = 4 for meningioma. Progression-free survival (PFS) was the primary outcome measure. Secondary outcomes were overall survival (OS) and treatment-related toxicity, according to Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5.0). Kaplan-Meier curves were used to estimate the effect of several parameters on PFS and on OS; Cox regression models assessed predictors of PFS and OS.

RESULTS

Between 2003 and 2021, 181 patients (pts) were included. They were re-treated with SRS (n = 75; 41.4%), f-SRT (n = 63; 34.8%), PT (n = 31; 17.1%) and conventional radiotherapy (n = 12; 6.7%). 78 pts were identified with WHO Grade I disease, 65 pts with Grade II and 10 pts had Grade III disease. 28 pts without histologic sampling were included among Grade I patients for further analysis. Median age at re-irradiation was 62 (range 20-89) and median KPS 90 (range 60-100). After a median follow-up of 4.6 years (IQR 1.7-6.8), 3-year PFS was 51.6% and 3-year OS 72.5%. At univariate analysis Ki67 >5% (HR 2.81, 95% CI 1.48-5.34, p = 0.002) and WHO grade > I (HR 3.08, 95% CI 1.80-5.28, p< 0.001) were correlated with worse PFS, whereas f-SRT (HR 0.32, 95% CI 0.19-0.55, p<0.001), longer time to reRT (HR 0.37, 95% CI 0.21-0.67, p = 0.001) and higher tumor BED (HR 0.45 95% CI 0.27-0.76, p = 0.003) favorably correlated with PFS. At multivariate Cox analysis only f-SRT, time to reRT and tumor BED kept their statistically significant prognostic impact on PFS (HR 0.36, 95% CI 0.21-0.64, p<0.001; HR 0.38, 95% CI 0.20-0.72, p = 0.003 and HR 0.47 95% CI 0.26-0.83, p = 0.01, respectively). In addition, larger tumor GTV had a statistically significant higher risk of acute and late toxicity (p = .0.004 and p = 0.005, respectively).

CONCLUSION

Reirradiation of RM progressing after previous RT seems to be feasible, with encouraging outcomes and an acceptable toxicity profile. Prognostic factors in the treatment-algorithm have been identified and should be adopted in clinical daily practice.

Impact of COVID-19 on patient-doctor interaction in a complex radiation therapy facility

PURPOSE

In the last months, Italy faced a COVID-19 emergency and implemented preventive measures in order to protect patients and healthcare providers from a disease outbreak. The pandemic control strategies impacted patient experience directly. Questionnaires evaluating patients reported measures (PREMs) may assess critical issues and represent a helpful tool to measure the patient perception of healthcare service. Our aim was to prospectively assess patient satisfaction about doctor-patient interaction in a high-volume radiation therapy and oncology center during the COVID-19 pandemic.

METHODS

Cancer patients receiving either systemic and/or radiation treatment underwent a survey. Two validated questionnaires (EORTC QLQ-C30, FACIT-TS-G version 1) and 14 specific questions evaluating patients' perception of COVID-19 measures were administered.

RESULTS

One hundred twenty-five patients admitted to our department from 1-30 April 2020 completed the questionnaires. The majority (66.4%) of patients were women and the most common disease was breast cancer (40%). The average Global Health Status (GHS) of EORTC QLQ-C30 was 61.67. Emotional functioning, social, and cognitive domains obtained scores of 75.48, 80.13, and 84.67, respectively. FACIT-TS-G results revealed 120 patients rated the treatments effective and 108 patients thought the side effects were the same as expected or better. Most (89.6%) rated their treatment good, very good, or excellent. Concerning COVID-19-related questions, patients reported overall very good level of information.

CONCLUSIONS

Despite the introduction of strict COVID-19 control measures, there was a high level of cancer outpatient satisfaction. The satisfaction levels may influence compliance, continuity of treatments, and patient-doctor communication, impacting the quality of clinical care in the next phases of the pandemic.

TomoTherapy treatments of multiple brain lesions: an in-phantom accuracy evaluation

Aim of the present study was to evaluate the accuracy which can be obtained with helical TomoTherapy^® (HT, Accuray) systems in the case of multiple intracranial targets treatments. Set-up accuracy was measured, for different registration options and MegaVoltage CT (MVCT) slice thickness, by applying known misalignments to an ad-hoc developed phantom. End-to-end (E2E) tests were performed to assess the delivery accuracy in phantoms containing multiple targets by using radiochromic films: measured dose distribution centroids were compared with physical and calculated target positions on axial and coronal planes. A Gamma index analysis was carried out on planned and measured planar dose maps. The bone and tissue algorithm with the fine MVCT reconstruction grid gave the best results among the automatic options. The most accurate registration modality resulted to be the manual one with a sub-voxel accuracy shifts and a capability in the detection of rotations within 0.3°. For the E2E along the coronal plane (six targets), a mean deviation between measured dose distribution centroids and physical barycenters of 0.6 mm (range 0.1 mm-1.3 mm) was observed. Along the axial plane (five targets), a mean deviation of 1.2 mm (range 0.7 mm-2.1 mm) was found for the centroids shifts. Gamma index (5%, 1 mm, local) passing rates higher than 87.5% between planned and delivered dose distributions were measured. These results demonstrate that multiple brain lesion HT treatments are feasible with an accuracy at least comparable to frameless linac-based delivery, when a set-up capable to assure angular corrections and a reliable patient immobilization is employed.

Impact of molecular subtypes classification concordance between preoperative core needle biopsy and surgical specimen on early breast cancer management: Single-institution experience and review of published literature

BACKGROUND

Core needle biopsy (CNB) plays a crucial role as diagnostic tool for breast cancer (BC). The characterization of biomarkers status before surgical treatment is crucial when primary systemic therapy is a therapeutic option. The aim of this analysis was to report concordance between preoperative CNB and surgical specimen (SS) in evaluating biomarkers and molecular subtypes.

METHODS

Data have been collected from a cohort of 101 patients affected by early BC treated at Careggi Florence University Hospital, between January 2014 and March 2015. The conformity between molecular subtype classification was tested using kappa (κ) test.

RESULTS

Mean age was 57.5 years (range 29-86). There was concordance between the estrogen receptor (ER) assessment on CNB and SS in 95 cases (94.1%). Concordance of the progesterone receptor (PgR) assessment was observed in 89 cases (88.1%). Concordance for detecting immunohistochemistry-assessed BC molecular subtypes was 87.1% (κ = 0.78). Concerning Ki-67 evaluation, we report a concordance rate of 88.1% (κ = 0.68). The evaluation of luminal A plus luminal B/HER negative subgroup showed a κ-value of 0.65.

CONCLUSIONS

CNB showed good accuracy in evaluating hormonal receptors status, HER2, and BC molecular subtypes. Evaluation of Ki67 status was less accurate than other biomarkers; therefore, we recommend that it should be detected both on CNB and SS samples, especially in hormonal positive HER2 negative tumors, in order to avoid a misclassification of tumor subtypes that could lead to an omission of potential effective systemic therapy.